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0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />3 V 3 z, w c(j� <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />OWNER/OPERATOR: <br />GwrPC, k <br />(If Applicable) <br />1 <br />(Please Print) (Title) <br />(Date) <br />ADDRESS: W ak Q r( Um V Cj <br />(Mailing Address) <br />5-VoGy-`�L'� C4� <br />(City) <br />PHONE: ( )-6 C� ) L4 k & - -rA, 1x7 <br />EH 23 046 (Revised 8/4/06) <br />4 <br />(State) (Zip Code) <br />I <br />